Time To Pay Attention: What The Newest ADHD Research Is Telling Us

Yesterday, a nicely executed study came out showing that ADHD persists into adulthood for about 30% of people who have it as kids. Not only does it persist, but regardless of whether it followed them into adulthood, people who suffered from it as children had a greater risk of other mental health issues, like anxiety, depression, antisocial personality disorder, substance abuse, and possibly even suicide. The risk of having a psychiatric disorder as an adult was, of course, much higher if ADHD persisted into that stage of life.

These connections aren’t exactly news: Other studies have arrived at similar results, but they’ve varied so greatly in the methods they used and the connections they found that it’s been hard to know the actual rates and risks of comorbidities over the long-term. So, the fact that the new study, done by researchers at Mayo Clinic and Boston Children's Hospital, used more reliable means (it was a large-scale, prospective study that followed kids into adulthood and quizzed them about their psychiatric health then and there) to arrive at the findings mentioned above is a boon to ADHD research. Child and adolescent psychiatrists and psychologists have been pretty well aware of the connection for years, but it’s good to have a well-designed study support it strongly.

So the question is then, what are we supposed to do with all this? How do these accumulating studies affect our understanding of the disorder? The short answer is that it’s probably pretty well time to revamp our approach to ADHD, which at the moment leaves a lot to be desired. Seeing ADHD as a chronic health problem whose earliest symptoms can be often be present around age three (and should be intervened with right then, in ways involving the whole family) is really what these studies are trying to get us toward.

A Relentless Trajectory

Part of the complication with childhood ADHD is that there can be more than one mental health issue going on. John T. Walkup, MD, the Director of the Division of Child and Adolescent Psychiatry at Weill Cornell Medical College and New York-Presbyterian Hospital (not affiliated with the study mentioned above), tells me that one of the issues is that we need to sort out what’s ADHD and what’s not. “There’s the hyperactive impulsive type of behavior, which is the most malignant,” he says. “These kids develop problems with disruptive behavior. If they don’t get treated, they accumulate disability at a relentless pace.” (More on this in a sec.) Then there are other kids who appear to be inattentive, but the underlying cause may be something else – like anxiety. “Anxious kids may also be off task, because they are worried, preoccupied, and restless. But they’re not really hyperactive.” Sorting out the cause of inattention in youngsters is one of the issues that deserve closer attention.

But back to the more “malignant” form of ADHD. Kids who fall into that category often experience the double whammy of having honest-to-goodness attention problems, a lack of emotion and behavior control, and experiencing the lifelong fallout of having the problems, which might be worse than having the problem to begin with. The psychological fallout can involve inadequate treatment or mis-medication, inadequate parenting, and a mishmash of problems at school. When kids start to see themselves as “bad” or “troubled,” things get worse. “They’re told they don’t ‘behave’,” says Walkup. “They don’t connect with parents, or peers; their social and academic status slips. They experience lots of failure over the years. It’s a relentless trajectory that can include oppositional defiant disorder, conduct disorder; they also have higher risk of alcohol and drug abuse. White males are typically the highest risk group.”

It’s a cycle that can last for a lifetime, and may be part of the reason that kids with ADHD have comorbidities like depression, anxiety, and even suicide risk, says Walkup. “These kids become demoralized and alienated if they don’t get good treatment. If you can relieve them of their burden, you will go a long way to improving their outlook and their behavior.”

Stopping the Cycle

Interrupting the ADHD cycle before it ends in demoralization – and, of course, depression or suicide – is the obvious answer. It may not prevent everyone with ADHD from developing another psychiatric issue, but it could reduce the numbers quite a lot. How to best nip it in the bud is up for debate, but the mental health community is beginning to work it out.

William Barbaresi, MD, Director of the Developmental Medicine Center at Boston Children’s Hospital and Associate Chief, Division of Developmental Medicine at Boston Children’s Hospital, who headed the new study, stresses that we need to overhaul our understanding and approach to ADHD intervention and treatment. “One of the major obstacles is that there continues to be, in the media and the general public, this trivialization and sensationalization of ADHD as an overblown problem that’s being over-treated. But, as we’re understanding more and more, this is a serious chronic problem that begins in childhood and persists into adulthood. For example, in our study, 80% of those individuals with persisting ADHD had other mental health diagnosis. And even for those whose ADHD didn’t persist, 47% still had another psychiatric diagnosis. We have got to create a system that’s designed to treat ADHD as chronic health issue, not just a kid disorder.”

And as with chronic health issues of other varieties, there are often very early clues. ADHD is no exception. Walkup points out that early symptoms can be seen in kids as young as three years old: the “dysregulated behavior” that’s often evident early on can be a very good predictor of what’s to come.

“Preemptive treatment is where the action is,” says Walkup. “This is much more effective than ‘fixing’ the problem after the fact. All these problems have early onset. We can really cut our health care burden enormously if we pay attention and intervene early.” Walkup points out how we have no problem calling a spade a spade with early signs of heart disease or diabetes – two famously chronic health conditions that benefit from early treatment if warning signs are heeded. But when it comes to ADHD (like any other psychiatric issues), suddenly “labeling” is a problem. “We suspend our medical logic when we get to these kinds of problems,” he adds. “But medical logic actually works very well here."

Barbaresi also makes the point that the state of health insurance isn’t helping matters any, since, he says, “in the US, it doesn’t cover in-depth testing – if you’re a parent and you’re referred to my center, I’m not permitted to do in-depth psych testing. Even though we know 60% of the kids I see will develop a learning disability or other mental health issue, I can’t obtain authorization to perform the psychological testing that children need at that stage.”

One way to address psychiatric problems early, says Walkup, is to ask parents at their newborn’s first "well baby" visit about their own psychiatric histories. “Maybe dad had attention problems when he was young, but didn’t get treatment; maybe mom has anxiety disorder. They’re both people who are struggling. If I were a pediatrician, I’d be on lookout for ADHD in the child at 4, 5, and 6, and new onset anxiety between 7 and 12 years. In the meantime, let’s make sure that the parents are parenting spot on with what we know to be best practices in parenting. Let’s put them on a pathway – because of family history – to do something personalized and preemptive for the child, because there may be genetic vulnerabilities. Just put a note in the kid’s file, and provide brief assessment and counseling along the way. Starting the dialog early makes it easier, and takes less time than bringing it up when problems have been present but unaddressed.” He adds that the two minutes it takes him to explain this is about how long it would take a primary care provider to explain why it's important to find out about psychiatric history and parenting styles. Time is a real concern among medical professionals, but spending a little extra for this purpose is certainly worth it. "We worry about helmets and seatbelts; but not morbidity associated with behavior.”

If doctors are worried about the cost associated with early screening, it beats trying to treat ADHD many years later, when it may have all kids of other comorbidities associated with it. Walkup points out that it actually doesn’t take a lot of sophisticated training to pick out warning signs: Screening by non-medical, but well-trained, personnel is certainly possible. Early methods of treatment, before drugs are necessary, are effective, says Walkup: Small changes in parenting styles, a little extra attention in the classroom, and maybe a parenting class at the local Y or church might make a significant difference in a child’s experience and behavior. “There are lots of family and behavioral methods that work; it doesn’t take a whole lot. We KNOW when these conditions present themselves. We should be anticipating and preventing. It’s so comparatively cheap when we begin this early.”

Drug treatments are the still in many ways the standard care for ADHD – whether they should always be used or how they should be used is fodder for another article. Barbaresi feels that medication is still the most effective treatment we have, “and it’s safe when provided to an appropriately diagnosed child with good follow up care. But meds are not a standalone treatment. Changes in the way child is taught, and the ways behavior is managed at home and school, are essential. Still, we always get asked, ‘is there a non-medication treatment to make my child’s ADHD symptoms disappear?’ And the answer is still, ‘no.’”

Changing our views of ADHD won’t happen over night. Just like with depression or any other mental health disorder, public (and media) perception still plays a big role. But hopefully, as we get a better handle on what mental health disorders are all about, we'll shed the stigma and welcome treatment a little more. As Walkup says, “If you have a problem and take care of it, there’s no stigma. But if you have a problem and don’t take care of it, then there’s stigma.”